Rehabilitation Nursing interventions that facilitate continuity of care between hospital and community settings

The transition from hospital to community care should begin during hospitalization and requires structured and collaborative planning. In this context, the Rehabilitation Nurse Specialist plays a key role in outlining a transdisciplinary plan that ensures continuity and effectiveness of care, promoting the client's autonomy and responding to their needs and those of the caregiver. This critical-reflective study analyzed relevant studies on the subject, with the aim of identifying interventions that can be implemented by the Rehabilitation Nurse Specialist to ensure a safe transition between different care settings. The results show that formal coordination between professionals, through the use of structured and confirmed communication tools, is essential for the effective transfer of clinical information. The early assessment of the client's social needs, as well as the implementation of educational strategies aimed at the client and the caregiver, are decisive for their safe reintegration into the community, contributing to the reduction of complications and hospital readmissions. In conclusion, Rehabilitation Nurse Specialists face challenges in maintaining continuity of care at the time of transition, and it is crucial to optimize communication between contexts in order to ensure the quality of the rehabilitation care provided.